ZOE Science & Nutrition - Should we be worried about strep A?

Starting point is 00:00:00 Welcome to ZOE Science and Nutrition, where world-leading scientists explain how their research can improve your health. In recent weeks, a number of children have died due to an invasive bacterial infection of Group A Streptococcus, more commonly known as Strep A. While most bacteria are our friends, this one is definitely not. It is common around the world, and cases of strep A infections usually rise in late winter and early spring. This year, figures show cases are rising much earlier than usual in the US, the UK, and other countries across Europe. Strep A usually causes mild illness. However, in rare cases, things can become much more serious. And this is happening more frequently than usual. Current data shows a more than three-fold increase

Starting point is 00:00:59 in cases of this invasive form in young children. Understandably, parents are worried. Unfortunately, much of the information available online is murky, and the usual misinformation is already circling on social media. So in today's episode, I'm joined by a world-leading expert on the subject, Professor Shirani Striskandon, whose scientific research focused specifically on strep A bacteria. I'm also joined by Tim Spector, one of the world's top 100 most cited scientists, my co-founder here at ZOE, who's been closely following infectious diseases in the community through our ZOE health study. Shirani, thank you for joining me today.

Starting point is 00:01:41 We'd like to start with a quick fire round of questions from our listeners. And we had a lot of questions from our listeners around this topic. I would say one of the largest set of questions that I've seen. And we have a very simple rule we always do for this, which is always really difficult for scientists, which is you can say yes or no, or a one sentence answer if you absolutely have to. Are you ready to go? Possibly. Looking a little anxious. It's not that bad, I promise. I took my little girl to the dentist yesterday and she was really anxious, so it won't be as bad as that. All right. So, is there a lot of strep A infection at the moment?

Starting point is 00:02:22 There is, yes. Can some children get really sick with strep? Yes, rarely. And should parents be panicking? Definitely not. Brilliant, see that wasn't that hard. Tim, is there an increased level of all infectious diseases like cold and flu and COVID this winter? At the moment, absolutely, yes. We're seeing lots of infections. Next question. We have this a lot. If my child has to take antibiotics for a strep A infection, will it destroy their gut microbiome? Probably not.

Starting point is 00:03:05 All right. Well, I think we're going to get into all of that now through the rest of the podcast. And I think, Shirani, what I'd really like to start with is, like, what is this strep thing that suddenly we're hearing about all the time? So this strep thing is a bacterium called group A strep, strep pyogenes, strep A, whatever you want to call it. And it's been around for a long time in our history, a long, long time. It normally causes infections of our throat. It can cause infections of our skin. But unlike some bacteria that you may have heard of, it's not something that normally lives in our throats and our skin. It's an abnormal bacterium. So it's not a friendly one

Starting point is 00:03:41 at all. And very rarely it can go to parts of the body where it shouldn't be and make us far more sick than we should be. But in general, it causes kind of these self-limiting infections of the throat or of the skin. And those get better quite often on their own, but more quickly with antibiotics. And how common is it normally? And how common, I guess, is it, you know, right at the moment around the world in this winter? So it's very common, but we see it in different seasons in countries like the UK and the US, for example, the Northern Hemisphere. So we tend to get sore throats from group A strep. Actually, interestingly, not in the peak winter season when we get the viruses that cause flu or RSV,

Starting point is 00:04:30 but usually actually in the early spring. And we don't really understand why that happens. But anyway, we get sore throats then. And I would say that every single child has had a strep sore throat by the age of five or six. So it is very common. And a lot of children, as we know, get sore throats quite frequently throughout the year. Many, many of those will be viruses. But we do know that most of them will have had group A strep by the time they're five or six. So it's not something that is alien to us as humans. What's really interesting is in hotter, more tropical countries, group A strep seems to cause more skin infections than throat infections. So you get more infections like impetigo or something called pyoderma,

Starting point is 00:05:11 which is a sticky sort of scabby skin infection. Both of these things are very infectious to other children though. So it's common when it causes these skin or throat infections, but it's not normal for the bug to live in the throat. What's odd this year is that it's coming at the same time as we're being hit by other viruses that particularly are also having sore throats as their top symptom. And this, I guess, is what Shari's saying, is particularly unusual, although every year varies. So, you know, there's this cyclical, just like

Starting point is 00:05:45 with viruses, for reasons we don't really understand, bacterial infections also vary year to year quite a lot. So at the moment, we've got this triple whammy of virus symptoms in children and adults that are causing sore throat as the number one commonest symptom, which also happens to be the sort of trademark symptom of strep throat. So that's why we're sort of in this particular pickle at the moment, that generally it would be out of season, you wouldn't have these competing other infections, which are all at the moment still going upwards.

Starting point is 00:06:27 Which makes it very difficult, doesn't it, for the poor old kind of parents and the doctors and clinicians trying to see the children, working out what on earth is going on. But it's also a double whammy because clearly one thing can make the other thing worse. And we know that from history. So we always know that, you know, somebody who has a pneumonia and has had something like flu or RSV beforehand will maybe do worse because of having both together. But what I would say is that group A strep has been climbing throughout the year in an abnormal fashion. So I don't think we can blame viruses for everything, but the fact that now we've got group A strep occurring in the wintertime when it shouldn't normally be doing that is clearly putting us in a bit of a problem.

Starting point is 00:07:07 And so you're saying that actually it's not just started in the last month or two as we got into the winter in the northern hemisphere, but actually you've already been seeing cases like throughout the year. And is that very much like a strange post lockdown, post COVID sort of phenomenon? Or do you see that in other years in the past also? I guess we're quite lucky in England in that we've been count a lot in terms of infections like this. So scarlet fever, which is kind of a very historic thing, we've heard about it in little women and so on.

Starting point is 00:07:40 So it was a really big deal at the turn of the last century. But we've been counting cases of scarlet fever since that time, since the 1900s. And we know scarlet fever, which is just a kind of a very odd phenomenon that can occur with a strep throat sometimes in some children. We know that's a kind of marker for how much strep throat is around. And really, it was very, very uncommon after sort of, I guess, the 80s and 90s and noughties. So we really didn't see very much of it. And then suddenly around about 2014, in the springtime, we suddenly saw a lot more scarlet fever. And we've been seeing that sort of going on annually, really. And then of course, when lockdown happened in March 2020,

Starting point is 00:08:22 those rates of scarlet fever and therefore strep throat kind of went away for a long period of time. And so it's not entirely new. But I guess at the beginning of 2020, it looked like we were in for another bad year. And then we didn't have that because we all kind of stayed indoors and stayed away from one another. And so I think what you're saying is this, interestingly, it's not just a sort of post lockdown occurrence. You're saying you've sort of seen this rise since about 2014, so almost a decade. So there may be more than just the sort of reassertion. Yeah, exactly. So we particularly, British Isles or England, has a particular apparent problem with group A strep, which has been going on for the last sort of eight years.

Starting point is 00:09:11 But it's obviously concatenated with all these other things to leave us where we are today, which is that we've got a kind of big rise now in the wintertime, which is not when we'd normally have it, coinciding with winter viruses, and also coinciding with kind of cohorts of children who will not have seen group A strep for the last two years. And we know that because we didn't see it either in the hospitals. And can I ask a bit more on sort of, I guess, why we care? Because you've just described something you said, like, it's a sore throat, and everybody gets it. So that doesn't sound like anything you need to worry about. But on the other hand, you know, we have a lot of listeners who are sort of panicking about

Starting point is 00:09:50 potentially really serious outcomes. Could you just talk us through that gap between something that sounds like we have no reason to worry and people, you know, I think, you know, really being worried about what might happen to their children? Well, so, I mean, this is kind of one of the reasons why we generally don't worry about a sore throat is that actually most of the time, even if it's caused by group-based strep, it often gets better on its own. And also testing for it is done differently in different countries. So, for example, we tend, GPs tend not to test for strep throat in this country, but in the US, they use rapid throat tests and so on. Why should we worry about it? I guess my view is that the reservoir, if you like, of this bug is in the community. It's the community of children with strep sore throats. And very,

Starting point is 00:10:35 very rarely, this bacterium can get into parts of the body that it should not get into. And I think it's really important to stress this is not just in the children who've got the strep sore throat. In fact, mostly it's not. They act as the reservoir for infections where the strep gets in, for example, through a break in the skin. I mean, that could be an accidental break, for example, injury, or it could be somebody with chicken pox or somebody with a pressure sore or somebody with surgical wounds and someone who's just had a baby. And if you have a massive increase in the community of people out there with a strep throat, the risk or the number of people who are going to then develop these much, much rarer invasive infections is going to be much greater. So it's a linear relationship, I guess, but we just don't know exactly

Starting point is 00:11:23 the nature of that relationship. So it's not just skin breaks. Also, clearly, the bug can get in past the throat into the lower respiratory tracts, into the lungs and cause a pneumonia or fluid on the lung, empyema, which is something that we've been seeing in children. And that probably is more likely when you've got respiratory viruses, but it can happen even without respiratory viruses. So there is one other thing I'm going to slip in, and that is that outside of countries which have access to good healthcare and prompt treatment, we know that if you have repeated strep infections in childhood, you can develop autoimmune problems afterwards. So even in children, they can get a disease called rheumatic fever, which can affect the heart valves and cause valvular heart disease.

Starting point is 00:12:11 I guess to clarify, the rheumatic fever is a consequence of the strep infection? Correct. It's an autoimmune consequence. So it's not the strep infection directly causing it, it's the immune response to it. And nobody really understands quite how that happens, but it's a disease that Britain knew all about back in the 1920s, 30s, and 40s. And in fact, even after the war, we had cases of rheumatic fever, and also something called glomerulonephritis, which is inflammation of the kidney. And basically, a number of different autoimmune problems that can arise after a lot of group A strep infections. So these are incredibly rare in England, and we just really don't see them very much. But in the developing

Starting point is 00:12:51 world, they are far more frequently seen. And that's probably due to access to healthcare. And the real, you know, worldwide, one of the reasons why people want a vaccine against this bug is not to prevent the annoying sore throats that we've been talking about just now. And actually, it's not even to prevent the deadly invasive diseases we've talked about. It's to prevent those autoimmune problems that can follow because worldwide, the biggest burden of this disease is actually in low and middle income countries, where they have lots of strep infections in kids, and then lots of these awful problems afterwards which affect the heart and the joints and so on and the kidneys.

Starting point is 00:13:31 And it's called rheumatic fever for that reason, Jonathan. So as a rheumatologist we'll learn all about autoimmune diseases and causing this pain and it's a very similar model to people who suffer from rheumatoid arthritis or juvenile arthritis. The body's immune system is reacting against it in a way itself. And I think that's the really interesting dark side of why we're so interested in this particular microbe. And so to make sure I've got this, because I think part of the reason everyone's confused is it's quite complicated, isn't it? You know, it's not really simple. In a sense, you're not so worried about most people getting this strep. It sounds like every single one of us is an adult.

Starting point is 00:14:14 You're saying has sort of gone through this and probably had it multiple times. It's the small number of people where you actually get this really serious infection where the bacteria is no longer on my throat, but actually it's either gone into my lungs or it's sort of gone elsewhere into my body. And at that point, it has the potential to be deadly. Is that right as one angle? And then the other part you're saying is even if it isn't deadly, it potentially triggers these autoimmune issues, which I live with for the rest of my life. Yeah, those things don't really tend to happen very often in wealthy, northern, temperate climates. And nobody really understands why that is, but it's probably due to sort of prompt treatment

Starting point is 00:14:53 that happens in those countries. And Shirani, just on the treatment, again, just to make sure we got the basic before we dive in even deeper. So what is the treatment, you know, and at what point? And I'd love also understand, like, what are the symptoms that you're looking for? If you're a parent, you know, I've got a three year old, so this suddenly shot up my list of things to worry about, you know, there's only so many you can worry about, that means you should do something. And equally the point, you know, the symptoms that say point you know the symptoms that say you know actually you could probably stay calm and give it another 24 hours because if I took my little girl

Starting point is 00:15:29 to the doctor every time she was sick it would be three visits a week. Yeah so I guess for strep throat or scarlet fever I mean the symptoms have been read out a lot haven't they in the media in the last couple of weeks but it's a child who is unwell and poorly with a fever, usually. They will have or they may complain of a sore throat or difficulty swallowing, but they may not because they may not be able to articulate that if they're two years old, for example, rather than three or four. But as a parent, you can actually peer into their throats. I wish people would do that a little bit more often. Obviously, try not to breathe in all of their droplets while you're doing that.

Starting point is 00:16:05 But I do encourage parents to kind of get to know their child's back of the throat because you can see a lot. And I mean, if you see big tonsils with white pus on them, that's not normal. The other thing is that children often will get big glands up in the necks, which you can feel and they will be tender. So that would be a good indication that they might have a strep throat because obviously a viral sore throat will give you a very red throat, may well give you a fever. It doesn't usually give you giant tonsils with pus on and kind of doesn't usually give you massive lymph glands in the neck. On the other hand, if they're very snotty and they've got lots of kind of mucus coming out of their nose and they've been sneezing, that makes it slightly less likely to be a group A strep. So those are sort of the indicators for a strep throat.

Starting point is 00:16:49 And in my view, it does need antibiotic treatment. Certainly at the moment, we're encouraging doctors to treat strep sore throats. And the other thing is it is infectious to other people. So I would encourage people that if their child has been diagnosed with strep throat, even if nobody remembers to tell them that they should not really go to school for at least 24 hours after they've started their antibiotics. So that's strep throat. And then scarlet fever is kind of, is exactly the same as that, except with the prickly rash, which can occur within, usually within a day. And it's a sandpapery rash, you can feel it and you can see it on the skin. It's like little bumps. So it's a bit different to something like a measles rash or anything else because you can

Starting point is 00:17:28 feel the rash. And so it might not be red if you've got a darker skinned child, but it's definitely there. And the children will get a very kind of bright red, prickly looking tongue as well called a strawberry tongue. So again, scarlet fever, absolutely very infectious, just like strep sore throat, needs antibiotic treatment. And that is the one situation where antibiotic treatment for 10 days is recommended and definitely stay away from school for at least 24 hours until the child's had antibiotics. But to be honest, most children, they're off school for two or three days because they feel rubbish. And that's so thankfully nature does does its bit to isolate the child and just another clarification on the scarlet fever because this is definitely again where it starts to get a little complicated is the scarlet fever

Starting point is 00:18:15 just a different set of sort of your symptoms to exactly the same infection or is it actually something different from this normal strep A infection you're describing? It's different insofar as you get this rash and that's what makes it scarlet fever. But remember the rash usually follows a sore throat by day. So quite often you'll have a child who has this bone door strep throat who may or may not get diagnosed with a viral infection rather than a streptosaur throat. And then quite often, it's only when the rash appears that the doctor or the parent realize, oh, it might be scarlet fever, or it might be something else. So I think they are basically

Starting point is 00:18:55 part of the spectrum of exactly the same infection. But who gets scarlet fever? Younger children, and children who probably haven't met some of the toxins that this bug makes that trigger this scarlet fever reaction so it's an immune reaction a direct immune reaction to the toxins that this bug makes it's a very old-fashioned disease the rash in itself is harmless it goes away but other children will have met the bug before and they may have got immunity to the bacterium already so they kill off the bacterium by their own immune system before the toxins ever get to cause the rash. It's the same thing. So just some comments based on the Zoe health study

Starting point is 00:19:33 where we're still monitoring symptoms from our viruses and COVID at the moment. Fever is actually pretty low on that list and it's also very low in COVID at the moment. We don't have accurate data. You may know more about very young children and covid i suspect it's pretty rare in those groups as well so the distinguishing feature is not so much the sore throat but it's this pussy really nasty looking tonsils that you know you need to see and a fever and really being very unwell yeah so i'm full disclaimer i'm not a pediatrician but i work on a pediatric infectious disease so we yeah we've looked at children who've had for example scarlet fever and we've asked questions of their parents

Starting point is 00:20:18 you know in a survey some time ago nothing is kind of spectacularly successful as ZOE app. But one of the things we found was that fever was a dominant feature of scarlet fever. And the other thing is that obviously younger children will tend to present interesting symptoms that you wouldn't necessarily normally associate with a respiratory bug. So they may start vomiting, for example. I think that's just something that young children do when they have an infection, they vomit. I can't really explain why. And it may just be that they get higher fevers than adults. I was going to say, you're both going to tell me you're not paediatricians, you're just like world famous doctors. But my impression from a sample of a few children is also they tend to run fevers more when they're very little than when they're older. Is that true or is that just like my unscientific

Starting point is 00:21:06 sample? I agree. But I can't say I've got any scientific backing. That's my impression as a parent. They're also worse at explaining what's going on. So I guess you're also, you're sort of, as you said before, I guess this is part of, I think, why one always worries a bit more when they're little, right? You're not sure that they can explain as clearly. And it's interesting what you're saying that, you know, at two, they may not be able to explain they got a sore throat. By the time they're three, they probably can. My wife's a dermatologist. And so, you know, she's always fascinated by the way the particular rash tries to tell you something. And I laughed as you explained about the sandpapery rash, because my wife is always pointing to something being like, obviously it's this sort of rash and i'm like it sort of all looks the same to me so i'm

Starting point is 00:21:49 i'm always feeling that these are the sorts of things that doctors say to regular people to figure out and it just creates sort of more anxiety about whether you've successfully identified a sandpapery rash versus maybe their skin is normally like this. Yeah, but it's also COVID rashes occur very late. So they don't occur, you know, the day after infection and things like this. So there are quite a few other differences here that, although any viruses can cause rashes generally. So they're not the same classical one as described here. But I think the key is the really nasty looking tonsils,

Starting point is 00:22:27 very sick, and the high fever that distinguishes it. And people shouldn't think, oh, this must be COVID because there's lots of COVID in the school. That's my view, because COVID isn't producing that fever that it was at the beginning of the pandemic. And I think that most people aren't aware of it. It doesn't even come in our top 20 list of symptoms in the ZOE data now. And I think that's really important. And I guess your message is, in general, they're going to be quite sick at the point you need to be worried. Is that also part of what we're taking away? Because I think that's often the question. So if you've got a two-year-old, you're going to be anxious. And so the question is you know at the first sign of anything are you straight off to the doctor or would you say still they're going to be quite sick could still be lots of other things that's what's triggering

Starting point is 00:23:13 how would somebody listening sort of help to sort of figure their way through as long as we're still talking about sort of the strep throat scarlet fever end of the scale children do get poorly they're not kind of gravely ill. They're just, they are poorly. They're as poorly as they can be. Like Tim said, you know, you might have the tonsils or the red rash or something that points you to the fact that the child is not having a simple viral infection, but it might be a bacterial infection. It might be a strep infection. What we're saying to parents at the moment is, you know, at the moment, there is a lot of strep about and far we're saying to parents at the moment is, you know, at the moment, there is a lot

Starting point is 00:23:45 of strep about and far more than there might normally be. And therefore, what might have been a virus in a normal year might well be strep and it might need antibiotics. And in those circumstances, you know, you can discuss it with your GP. But in many countries, get a rapid test because, and there are places in the UK, according to my paediatric colleagues, that do offer some rapid tests. And as well as most European countries, you can get rapid tests done. So the UK is rather unusual in that it doesn't provide that for primary care services.

Starting point is 00:24:21 And Tim, I actually really wanted to ask about this. I had a comment from one of our listeners that I loved, which said, I've lived in the USA, so I know all about strep throat. Why is it I've never heard of it in the US when I was little. And she said I had antibiotics for strep throat about 10 times in my first five years while I was living in the US, while my sister, who's much younger, was born in the UK and she never had it once. And so it's sort of really fascinating to me because I had thought maybe it's just a disease that miraculously isn't in the UK. I didn't really think it was very likely. Shirani is like shaking her head like, of course not. Could you help us to understand why this is a thing that like, you know, my many friends

Starting point is 00:25:14 in America tell me about three times a winter that they have strep, their children have strep, and that if you're in the UK, like no one has ever mentioned it until today. It seems really mysterious. I think the problem lies not in, yeah's not in the not in the microbe itself which is probably similar in both countries but in the health care systems of uh both countries is my view so i think there's a sort of cultural difference isn't there like you say between uh the uk and other parts of the world decisions about treatments are made on a sort of cost benefit basis on the individual. So for example, the decision even to, you know,

Starting point is 00:25:51 that you don't, you might not need to treat a strep throat is very different in this country compared with other parts of the world. That's because we don't tend to see these, these complications of strep throats, the rheumatic conditions that Tim mentioned earlier. But if you go to somewhere like Australia and New Zealand, you will see posters up in surgeries saying, get your strep throat checked out and get treated. So on the one hand, we've got posters up saying, don't come to your GP with a sore throat. They've got posters saying the opposite. And look, you're one of the world experts on strep. So just, you know, for your own personal view, like, should we be testing for this? Put aside like any cost question, but just like, should we be testing and then treating

Starting point is 00:26:31 or should we just not? Where would you go? If cost was not an issue, then I think it would be great to test and treat, but you need to really target the testing to people who've got a high probability of having a strep throat in the first place. So there are all these kind of clever algorithms that people can use. Is it likely to be a strep throat or not? A bit like what we discussed earlier, like are there big tonsils? Are there glands up in the neck? And the thing is that these tests are either very sensitive, which means they're based on a DNA test, a PCR test. We all know what those are now, but a lot of them are based on lateral flow type thing. Again, we know what those are.

Starting point is 00:27:09 And the lateral flow ones are 85% sensitive. That means that in 15% of cases, they miss the bug. So I think for a general population use, that's probably okay, you know. And so for a doctor to be able to use a test and a sort of clinical decision making tool in their brain would be helpful and then they could maybe they would prescribe potentially fewer antibiotics we don't know and i just want to pick up on the end because actually antibiotics is something we had lots of questions on and i think you know this being you know a show that's

Starting point is 00:27:39 related to nutrition and we talk about gut health and i think the antibiotics here is fascinating because we know they can save your life in lots of places right so that's also really important we also now know that they can have um unexpected negative impact over time that we probably didn't understand a long time ago but i'm interested you said that you might actually prescribe fewer antibiotics because i'm thinking about this US experience where in general I think we see this actually in our own data and our own members where people in the States generally have had far more courses of antibiotics by the time they're 18 and then far more also in their adult life. So it's interesting that you were suggesting that testing might actually reduce it. What are

Starting point is 00:28:24 your thoughts? I think there are two things there. First of all, there's kind of healthcare use. I don't think we tend to go to our GPs very often. I mean, and that's for things like sore throats, that attendances to general practice have been declining for like two, three decades. I mean, I think we're quite, the British public is pretty well educated. They know not to kind of go to their GP, just like you said, with every kind of cough and sniffle. We don't do that. But actually, in Europe, for example, they may well go and get something prescribed, even if it's not an antibiotic. We would not dream of doing that. So there's that. And the one thing, we're not going

Starting point is 00:28:56 to see our doctors to get prescriptions in the first place. But it was really just the thing, the idea that if you did a test that could distinguish this is a bacterial infection from this isn't a bacterial infection, i.e. it's a strep throat or it's not, it would help the doctor in making that prescribing decision. Now, we don't know whether that would increase or decrease antibiotic prescribing. I just would like to optimise it. I prefer doctors just do the right thing. I'm not interested in how much antibiotic is prescribed as being a metric because i'd rather treat the patient i think that makes huge sense and i think you know as a company that's very much around believing in understanding the data and also having more control over yourself it seems pretty

Starting point is 00:29:37 obvious that you would like to understand um what you have if the costs are manageable and i think the problem is that the tests that are used in many parts of the world are not brilliant, but they are cheap. And the tests that we use in the UK is really good because it's culture. And also we can then get the bug and we can test it for antibiotic susceptibility and resistance, which you can't do if you do any of these other tests. But it does take, you know, you have to get the swab to a lab for culture and for a gp that means you won't get the result back for one or two days so it's not very practical for them i understand sure and i was also thinking you were saying that people in the uk are really well trained not to go to their doctors when they're sick that there'll be all these other

Starting point is 00:30:18 listeners around the rest of the world saying that sounds completely mad so that they've all been trained basically not to see their doctors. I don't want to get pulled down. That's a whole podcast in and of itself. Well, I think we are all being told that they're overloaded and you really shouldn't bother them unless it's really important. So, yeah, things have definitely changed in the last few years as people don't want to wait and queue up for hours and hours

Starting point is 00:30:43 to see an emergency doctor. They're more likely to go to casualty than that. But I slightly dispute the fact that the British are perfectly well behaved and don't take many antibiotics because the data doesn't show that. It shows that there is a gradient across Europe where the Scandinavians take the least antibiotics, where they have the best health care, their point of care testing, and they take about half the levels of antibiotics that we do in the UK. Although we're much better than many of the South Europeans, places like Greece and Cyprus, etc., have really massive overuse of antibiotics as well, where they can get them from pharmacies and much more easily available. So I think most people agree that we could do a lot better than the Netherlands is much better than us, for example, in total amounts of antibiotic use. So we are overusing it. And this

Starting point is 00:31:38 does cause major problems. The more people use antibiotics, the less effective they become, and you get more resistance to other bugs as well. So I think there's obviously a fine line here and there's difference about talking in general about antibiotics and also very specifically about this particular problem of strep throat. And so Tim, could we talk maybe just about the strep for a minute, just about, I guess, your perspective, given what Sharani was saying as well about, I guess, antibiotics with strep A. I know you're going to say that if children are really sick, then they should definitely use antibiotics. We've often talked about how life-saving this is, but there obviously is an interesting balance. And I think partly also I'm hearing that potentially at times when it's very severe,

Starting point is 00:32:22 like now, you might also, I think that's what I'm hearing from you, Shirani, you would go to the antibiotics potentially sooner because of this level than elsewhere. But what are your thoughts? Because I think there are a lot of people, having read your books and the rest of it, who are probably much more cautious about antibiotics than they would have been a decade ago. Yes. So for those of you who aren't aware, I mean, there is this data showing that antibiotics are not harmless. We thought they were this free magic bullet that really had no secondary effects that you could take them preventively for anything really, and they wouldn't do you any harm. But we know that in animals, they've been used for the last 30 years to increase the growth of animals and the size of animals. And so they have been

Starting point is 00:33:12 associated with increasing obesity, lots of rodent studies showing that small doses of antibiotics or repeated doses can increase levels of body fat. And the epidemiology around that, it does suggest, it's not overwhelming, but it does suggest that there's a link in observational studies between kids that have large numbers of antibiotic courses and increasing allergies later in life. So these are not like you're bound to have allergies. These are relatively small increases, but more likely to have problems with obesity or with allergy if you've had many antibiotic courses. But I'm absolutely not saying that if your kid has

Starting point is 00:33:58 a very sore throat, a fever, feels unwell, give that kid antibiotics. That's really important. It's, oh, well, someone in their class had a sore throat and was given it, I'm giving little Johnny the same thing. So I think it's where you draw the line. And I think this is where, you know, it gets really tough. So perhaps I can come in and talk a little bit about this. You referred to mass use of antibiotics. Unfortunately, I think the press has kind of somewhat over over egged that and shirani can you give a bit of context because not everyone i think so there are two situations where the use of prophylaxis so that's preventative antibiotics

Starting point is 00:34:37 for people who are not ill at the moment uh have been discussed one is where there is a significant outbreak of scarlet fever in a school or a nursery, which is not being controlled by standard intervention. So normally what happens when there's like two kids in class with scarlet fever is the school's given lots of advice about hand and respiratory hygiene, about good ventilation, and making sure that any child who is diagnosed is given antibiotics and stays at home for at least 24 hours, and all of the kind of usual stuff that they're told to do. But sometimes it's just not possible to control the outbreak, and you get more and more and more children in the class going down with infections. So it's been discussed in that setting. Now,

Starting point is 00:35:20 in the past, that has very rarely ever been done, and it's only ever been done on a sort of single class basis. When it's happened, it has been effective in terminating the outbreak. Now, what's the rationale for that? Well, we know, because we've tested these kids in a previous year, that actually up to half the children in the class can be infected with exactly the same strain. They may not be ill with it, but they may be capable of transmitting it. And some of them do go on to become ill with it. So the rationale is we know it is super infectious. I mean, it's at least as infectious as flu is.

Starting point is 00:35:57 And Sharani, I guess the real answer to this would just be to have a vaccine, like we have developed for COVID. And I understand this is something that you're actually working on. Well, I mean, some people have been working on their entire careers, and it's something that people were working on 100 years ago. And we have still not got one. And there's many reasons for that. One is that it's a devious bug.

Starting point is 00:36:23 It's so difficult for our immune systems to get over it, right? Because it has everything in its power. It does everything in its power to kind of wallop our immune system. So it's a very clever bug. I've said this before, it's a proper pathogen, a card-carrying pathogen. So that makes it difficult. You don't need just a little bit of immunity. And it's a bit more complicated than a virus. I mean, sorry, virologists out there. We don't want you to get into a special battle now between, you know. SARS-CoV-2 is really simple compared with group A strep. I mean, it's got 1,800 genes that can make proteins.

Starting point is 00:36:58 So that's how many possible targets for a vaccine you might have to consider. But in reality, we've had lots of ideas over the decades for how to vaccinate against this bug. But it's been difficult. And that's partly because it comes in over 200 different kind of flavors, types, if you like. So that will be quite difficult for a vaccine to cope with. But there are other ways of dealing with that. So it's not about to roll out next year then, Shirani? Correct. Now, to be clear, I hated the lockdown. It was miserable for my mental health, but it is very interesting that in a sense, we're

Starting point is 00:37:35 suddenly paying attention to these things. And I know Tim talked about this through the Zoe Health Study. So hopefully there will be some more silver lining out of this and more focus on these vaccines and everything else. And our immunity maybe as well, you know, that's the other thing about how to protect ourselves against infections more and things that damage our immune system. I really wanted to finish with that, actually, which is just, you know, a lot of people in listening, we'd like to give some actionable advice. And I think one thing I'd love to just discuss, maybe Tim, you could give us maybe three top tips for our listeners, like on what they could do if they wanted to boost their

Starting point is 00:38:14 immune system, try and keep safer and healthier this winter. What would you be saying to them? And maybe also thinking about what you might be able to try and do with your kids, which I have to say is always a lot harder than things you want to do for yourself yeah i presume there's not many two-year-olds listening to this so i i suspect that they will have turned off this wonderful podcast some time ago so certainly for for adults uh, we showed very nicely with over a million people that your diet has a big effect on your immune response to viruses. So actually having a diverse, gut-friendly, plant-rich diet, low in ultra-processed foods, does have a demonstrable effect when you look at really big samples like that, as we showed. So we don't know for sure, but we're assuming that is going to be a similar effect on our immune reaction to other bugs, whether they're viruses or bacteria. So

Starting point is 00:39:18 be able to suppress them early, stop them going on and lingering and causing other problems, I think is important. To have a really good functioning immune system, you need a good functioning gut microbiome. That's the community of microbes in your gut. And to do that, then you need this diverse, plant-rich, high-fiber diet that many of us have stopped eating as we've gone towards more and more ultra-processed foods. So I think that's absolutely number one. And diet is the main thing that everyone can do something about. They can make their food choices.

Starting point is 00:39:52 And we believe that probably also applies to children. Over 70% of calories in children now come from ultra-processed food in the UK and the US. And that's getting worse. They harm the gut microbes. So giving them real food is really important, more fiber. We think pets are important. Getting dirty is important. Getting kids playing in the soil, as long as it's relatively not infected soil, is a good thing. Walks in the forest, a smelly dog, all these things seem to give extra benefits for our gut health. And as well as, you know, don't take unnecessary treatments like antibiotics, as we've discussed,

Starting point is 00:40:32 but it's clearly a virus and it's self-resolving. So I think they're the three things, diet, getting dirty, and avoiding unnecessary antibiotics are my tips we think that kids particularly in the first five years of life that's when their microbiome which is going to keep their immune system healthy is forming it's obviously the most crucial to to help them then and that's that's where we're letting them down particularly diet wise at the moment that was brilliant tim and sharoni and tim thank you so much for taking the time on this like i think very topical issue that a lot of people are really anxious about i always try and summarize now i am absolutely not a doctor so please correct me if

Starting point is 00:41:16 anything here i uh i say is wrong um and i think the starting point that you you all said is you know if you have any concern with your child of of course, you need to go and see a doctor. And this podcast is not medical advice. Having said that, the first thing we said, Shirani, I think you said was don't panic. So, you know, keep this in its right place. There is much more strep probably than ever before, and certainly much more than in the last few years. In terms of what you're looking for, this're probably thinking about your children, although you did mention some people who

Starting point is 00:41:48 may be in older age and their immune system may not be so strong, but in your child, they're going to be unwell and normally can have a fever. They may complain of a sore throat if they're old enough to explain that. In some cases, they develop this wonderfully termed scarlet fever, which definitely makes me think of sort of 19th century novels and people in the Wild West. Sandpapery skin, if you're better than me at being able to tell the difference between the skin, and it's called scarlet fever. But if your child has darker skin, you're not going to see that color of Shirani. Is that right? Correct. Yeah. So really, the skin is what you'll see. I think you both said this wonderful thing of

Starting point is 00:42:28 get to know the back of your child's throat, which no one has ever said to me before. I have no idea what the back of my children's throats look like, but I'm going to go and have a good look later tonight. And I think you said the big giveaway, if I understand on this on Strep, is you're going to see these like giant tonsils with pus. And I assume that is not what I'm normally going to see if I look. Is that right? Well, correct. But I mean, you need to kind of get looking, right? To know what your

Starting point is 00:42:53 child's throat normally looks like. I do. So I need to get the benchmark of not sick, which is difficult because I think my daughter has literally, as I said, been nonstop sick for the last six weeks. So actually quite hard to get, but I'm going to try and see like where it's smaller. So that will standardize. And remember, you might not see tonsils in the smaller kids. That's really helpful. So do send in photos of, I'd say our social media is going to be overwhelmed by tonsil pictures for the next week.

Starting point is 00:43:19 So I think that will be quite fun. So do share. I think that'll be fascinating. That might be a whole future study. And in terms of antibiotics, like I think Tim gave a very careful explanation. And I think, you know, my summary was going to be, you know, if your child is really sick,

Starting point is 00:43:34 then get antibiotics. If not, you know, be aware that it can, you know, there can be some long-term negative impacts. So be thoughtful. And we know that there are a lot of countries of which, you know, the US is probably at the top, but the UK is also quite high, where we can have a lot of overuse. And like, you know, we see this with, you know, as I said, some of our participants, where they have a rather extraordinary number of courses of antibiotics through their life.

Starting point is 00:43:58 Brilliant. Thank you both so much. I really enjoyed this. I have learned a lot. It definitely makes me feel more relaxed than uh than i was at the start of the podcast which i think is fantastic and i imagine there may be a whole bunch of parents and grandparents who also sort of feel um that sort of with this better understanding they can be a bit more relaxed thank you so much uh shirani for joining us tim for joining us as you do so often. I hope you enjoyed yourself. Thanks very much. Yeah. Thank you, Shirani and Tim, for joining me on Zoe's Science and Nutrition Today.

Starting point is 00:44:33 At Zoe, we want to improve the health of millions. If based on today's conversation, you'd like to understand how to look after your health this season, you may want to try Zoe's personalized nutrition program. Your Zoe membership comes with our app and access to our nutrition coaches, so you can learn how to change your diet and health habits and reach your long-term goals. Your Personalized Nutrition Program is based on our scientific research and the results of your personal at-home test. If you're interested in learning more about Zoe, you can head to

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Starting point is 00:45:31 See you next time.

ZOE Science & Nutrition - Should we be worried about strep A?

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